What is the best antibiotic for traveler's diarrhea?

From the Guidelines

Azithromycin is the best antibiotic for traveler's diarrhea, typically prescribed as a single 1-gm dose or 500 mg daily for 3 days. This recommendation is based on the strongest and most recent evidence, which demonstrates azithromycin's efficacy in reducing symptom duration and its superiority over other antibiotics, such as fluoroquinolones (FQs), in achieving clinical cure, especially in cases of dysentery or acute watery diarrhea with fever 1.

Key Considerations

• Azithromycin has been shown to be effective against a wide range of bacterial causes of traveler's diarrhea, including Campylobacter, Shigella, and enteroinvasive E. coli 1.
• The use of FQs, such as ciprofloxacin, is limited by increasing resistance rates in many regions, making azithromycin a more reliable choice 1.
• Rifaximin, a nonabsorbable antibiotic, is an alternative for non-invasive traveler's diarrhea caused by diarrheagenic E. coli, but its efficacy is lower compared to azithromycin and FQs in cases of invasive pathogens 1.

Important Notes

• Antibiotics should be reserved for moderate to severe cases of traveler's diarrhea, with fever or bloody diarrhea, as most mild cases resolve on their own with hydration 1.
• Preventive measures, such as drinking bottled water, avoiding raw vegetables and unpeeled fruits, and maintaining good hand hygiene, are crucial in reducing the risk of traveler's diarrhea.
• Oral rehydration solutions should be carried while traveling to prevent dehydration in case of diarrhea.

Side Effects and Safety

• Azithromycin is generally well-tolerated, with minimal side effects, usually dose-related gastrointestinal complaints 1.
• FQs have several concerns regarding adverse effects, including the potential for Achilles tendon rupture, an increased risk for C. difficile infection, and rarely the prolongation of the QT interval that may lead to fatal dysrhythmias 1.

From the FDA Drug Label

XIFAXAN is a rifamycin antibacterial indicated for: • Treatment of travelers’ diarrhea (TD) caused by noninvasive strains of Escherichia coli in adult and pediatric patients 12 years of age and older (1.1)

The best antibiotic for traveler's diarrhea is rifaximin for patients with noninvasive strains of Escherichia coli, as indicated in the drug label 2.

• Key points:
  • Indication: Treatment of travelers’ diarrhea caused by noninvasive strains of Escherichia coli.
  • Patient population: Adult and pediatric patients 12 years of age and older.
  • Limitations of use: Do not use in patients with diarrhea complicated by fever or blood in the stool or diarrhea due to pathogens other than Escherichia coli.

From the Research

Best Antibiotic for Traveler's Diarrhea

The choice of antibiotic for traveler's diarrhea depends on various factors, including the severity of symptoms, travel destination, and the presence of underlying medical conditions.

• Azithromycin is considered a preferred first-line antibiotic for the treatment of acute watery diarrhea and febrile diarrhea/dysentery 3, 4, 5.
• Levofloxacin and ciprofloxacin are also options for acute watery diarrhea and febrile diarrhea/dysentery, but their use is limited due to increasing fluoroquinolone resistance 3, 4.
• Rifaximin is an alternative for acute watery diarrhea, but it should not be used for invasive illness 3, 4.
• The use of loperamide in combination with antibiotic treatment can help reduce gastrointestinal symptoms and duration of illness 3, 4, 5.

Considerations for Antibiotic Choice

When choosing an antibiotic for traveler's diarrhea, it is essential to consider the following factors:

• Travel destination: The prevalence of antibiotic-resistant bacteria varies by region, and the choice of antibiotic should take this into account 3, 4.
• Severity of symptoms: Mild cases of traveler's diarrhea may not require antibiotic treatment, while moderate to severe cases may require antibiotics such as azithromycin, fluoroquinolones, or rifaximin 4, 5.
• Underlying medical conditions: Patients with certain medical conditions, such as diabetes or hypertension, may require special consideration when choosing an antibiotic due to potential drug interactions 6.

Prevention of Traveler's Diarrhea

Prevention of traveler's diarrhea is crucial, and measures include:

• Avoiding ingestion of contaminated food and water 7.
• Using prophylactic medications, such as bismuth subsalicylate or antibiotics, in certain situations 4, 7.
• Practicing good hygiene and safe food selection 5, 7.